Provider Demographics
NPI:1497178453
Name:ROSS, JAMI LYN (LCSW, LICSW, CCTP,)
Entity Type:Individual
Prefix:
First Name:JAMI
Middle Name:LYN
Last Name:ROSS
Suffix:
Gender:F
Credentials:LCSW, LICSW, CCTP,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 OAK CYN STE 150
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-5230
Mailing Address - Country:US
Mailing Address - Phone:949-508-1646
Mailing Address - Fax:833-884-9400
Practice Address - Street 1:6201 OAK CYN STE 150
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-5230
Practice Address - Country:US
Practice Address - Phone:949-508-1646
Practice Address - Fax:833-884-9400
Is Sole Proprietor?:No
Enumeration Date:2014-01-28
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3242G1041C0700X
MO20130140331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
13974157OtherCAQH PROVIDER ID
MO1497178453Medicaid
MO1497178453Medicare PIN
13974157OtherCAQH PROVIDER ID
MO1497178453Medicaid
MO1497178453Medicare NSC